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Friday, December 4, 2009

Overwhelming Relief

I've been thinking about this analogy for a while (I may be stealing this from someone, but I don't recall, so my apologies in advance) and was reminded of it again with the latest brouhaha about the "new" USPSTF mammography guidelines.

Scenario 1:A fireman who is also an arsonist, who comes to your house and sets it on fire. You desperately work to try to contain it and you're not sure you're going to be able to save the house. Thankfully, the fireman/arsonist comes back w/the rest of the fire department and they put out the fire. How do you feel? Are you grateful? Are you relieved? Are you angry?

Scenario 2:A doctor recommends a mammogram. It is abnormal, making you worried that you have cancer. You can't sleep for 2 wks, and ultimately get an invasive biopsy, which turns out to be normal. How do you feel? Are you grateful? Are you relieved? Are you angry?

The times I've been the doctor in scenario 2, patients are invariably so relieved when they find out that they don't have cancer, they forget to be angry that I was the one who caused this unnecessary worry and invasive procedure. They thank me for taking such good care of them. And I'm certain that they tell their friends how wonderful the mammography test is, and how they should get it as well. I'm sure some of the backlash against the new USPSTF guideline are from women who have had this experience which ended with relief, leading them to remember the whole experience in a positive light.

I'd love to better understand the psychology of what's going on here. I don't know if there's a solution, but I wonder if there are important lessons in decreasing the overuse of medical interventions in this example.

4 comments:

...just kidding, Sei, great post. The analogy sort of breaks down because the physician actually has some chance of being helpful in ordering the mammogram. So if the arsonist were somehow setting the fire with a helpful intent...hmm..."a visiting fireman doing a field test of house flammability unfortunately sets fire to the house?"

How could the USPTF have done better at managing the message? Maybe reducing opponents arguments to the absurd - why not screen all women in their 30's? 20's? Teens?

You live in a house in the woods at high risk for wildfires. Firefighters set a "controlled" burn that's supposed to minimize the dangers to your house. Unfortunately, the winds change and the fire heads toward your house. The firefighters come back and help you minimize the damage to your house.

Hilarious analogy--which is based in some truth. In the mammogram controversy, it was distressing to see serious issues so trivialized by the media. It was also disappointing how the guidelines themselves were misrepresented. The guidelines did not state that women in their 40's should not get mammograms. It said there should not be a public health recommendation for routine screening. The press ignored this subtle but critically important difference.

The guideline noted that it was not clear that the benefits screening outweighed the risks in this age group. But importantly, it noted that individual women in their 40's might conclude that for them the benefits outweighed the risks, and in these cases, screening would be reasonable. (Contrary to the portrayal in much of the media, this would be each woman's decision--not the government's or insurance company's decision).

In terms of cancer screening in the elderly, while the arsonist example may not be accurate in terms of intent, it has pedagogical use in making the point that an unthoughtful screen everyone approach can seriously harm elders. PSA screening is an example. As Louise Walter's work shows, PSA screening is very common in frail older men very unlikely to benefit from PSA screening. However, thie screening can lead to very morbid additional testing, biopsies, and surgeries.

I too would like to know more about the 'psychology' behind some of the highly charged comments made re the new mammography recs. I imagine it's in the realms of 'cognitive dissonance' and fear...

I have argued, unsuccessfully, with several people that mammography should be like the PSA for men. General recommendations should be just that; the decision of any individual would best be an informed one, using both the general recommendation and the considered advice of their physician. One more job for the primary care doctor - but, hey, that's what the primary care doctor should excel at - offering the best/most reliable information available and supporting good decision making for each patient. The arguments against this - there's no time and some doctors aren't so good at it even if they should be - are, sadly, not untrue. That doesn't mean we shouldn't aspire to the ideal.

Maybe more controversially, I believe that expert panels like the USPTF should be empowered to set insurance payment limits, at least if the government is the payor. Yes, it might be (barely, slightly) worthwhile for a 40 year-old woman (or very worthwhile by her calculus) to obtain a mammogram, but we just can't pay for it. She can. I would consider this 'reasonable rationing' (RR); others just see the latter of those big R words and go nuts.

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